HHS’ Office of Civil Rights Focuses on Title VI Policy


Provides Guidance for Ensuring Linguistic Access


By Houkje Ross


Closing the Gap, Cultural Competency Part II • February/March 2001


I

n August 2000, the U.S. Department of Health and Human Services’ (HHS) Office of Civil Rights (OCR) released a written 

policy guidance to help ensure that persons with limited English 

skills can effectively access critical health and social services. 

The guidance outlines the legal responsibilities of providers who 

receive federal financial assistance from HHS. Providers such as hospitals, HMOs, and human service agencies now have an outline for 

complying with the “Policy Guidance on the Prohibition Against 

National Origin Discrimination As it Affects Persons with Limited 

English Proficiency.” The guidance applies to 

part of Title VI of the Civil Rights Act of 1964, 

release that, “Effective communication is the key to meaningful access, whether it is a hospital, a clinic or a benefits program. Failure to 

communicate effectively can have serious consequences for millions of 

Americans.” 

According to the Cross Cultural Health Care Program (CCHCP), 

a nonprofit organization in Seattle, many institutions are now depending upon family members, friends, or support staff such as receptionists and technicians, to provide language assistance. But family 

members are notoriously bad interpreters because they routinely edit, 

add, or change messages from patient to doctor, according to CCHCP. 

which prohibits discrimination on the basis of “No person in the U.S. shall, on the Providing health care across language 

national origin. ground of race, color or national barriers without the use of an interpreter can 

Publication of the OCR guidance makes be like walking blindfolded across a minefield. 

HHS the first federal agency to publish guid- origin, be excluded from participa- The practice can be dangerous, and in some 

ance since the issuance of Executive Order tion in, be denied the benefits of, or cases, life-threatening. 

13166 on serving persons with limited En- “A doctor in our hospital was treating a 

glish skills. Signed in August 2000, the execu- be subjected to discrimination under diabetic patient who only spoke Spanish,” said 

tive order requires each federal agency to have any program or activity receiving Estela McDonough, coordinator of training 

written policies on providing effective service and education at the Interpreter Services Pro- federal financial assistance.” –Title VI to those with limited English proficiency who 

are served by federally funded programs. 

The OCR policy guidance recommends that health care agencies 

and providers develop a plan for providing written materials in languages other than English. This should be done in areas where a 

significant number or percentage of the affected population needs 

services or information in a language other than English to communicate effectively. To ensure satisfactory services to limited-English- proficient (LEP) clients, providers also should: 

❖ Have policies and procedures in place for identifying and assessing 

the language needs of the individual provider and its client population; 

❖ Provide a range of oral language assistance options, appropriate to 

each facility’s circumstances; 

❖ Provide notice to LEP persons of the right to free language assistance; 

❖ Provide staff training and program monitoring, and 

❖ Establish a plan for providing written materials in languages other 

than English. 

Meaningful Access Must be Provided 

According to OCR, agencies and providers must 

ensure meaningful access to LEPs. Office of Civil Rights 

(OCR) Director Thomas Perez commented in a press 

gram at the University of Massachusetts Memorial Medical Center. 

According to McDonough, the doctor said he did not need an 

interpreter because he said he knew Spanish. But the physician failed 

to pick up that the patient had been fasting due to religious beliefs. 

The patient was in a much more serious sugar crisis than the physician 

was aware of. Luckily, the interpreter had stayed in the room as a 

precaution. “Later on, the doctor told me that for many years he 

thought he had been communicating accurately with his patients. He 

had no idea he was putting his patients at risk,” said McDonough. 

Interpreting - More than Words 

Interpreting is more than just translating the words, according to 

McDonough. “The interpreter acts as the conduit between the patient and the health care provider. A trained and qualified interpreter 

has to have certain skills, including memory, concentration, knowledge of medical terminology, anatomy, physiology, and an understanding of how to deliver a message in the target language,” she 

added. 

Using professional on-site interpreters is a more reliable approach 

for providers because these persons have been screened for their language skills, trained in interpretation ethics and techniques –which 

includes learning to be accurate, complete, and to consider cultural 

frameworks— and contracted only to interpret, according to CCHCP. 

Professional interpreters should also have a good grasp of the 

nuances of culture and language, according to McDonough. 

“I had an interpreter who came to our program from Europe. She had a full year of training in Spain, but she still 

continued>>>> 

Office of Minority Health Resource Center	 1 U.S. Department of Health and Human Services 
HHS’ Office of Civil Rights Focuses on Title VI Policy


Provides Guidance for Ensuring Linguistic Access


By Houkje Ross


Closing the Gap, Cultural Competency Part II • February/March 2001


misunderstood what the patients from Puerto Rico were saying when 

describing “fatiga,” which in her native Spain means “tired.” For the 

patients from Puerto Rico, “fatiga” is a word used to describe wheezing 

from asthma,” said McDonough. 

Massachusetts is one of a handful of states that has standards for 

the use of medical interpreters. The Massachusetts Medical Interpreter Association’s (MMIA) standards address issues of interpreter 

skill, behavior, linguistic and cultural knowledge, and ethics. In April 

2000, the Massachusetts Emergency Room Interpreter Bill was signed 

into law. The law requires that all hospitals, public or private, which 

provide acute care, either in emergency rooms or in acute psychiatric 

facilities, when treating non-English speakers, must use competent 

interpreter services. The law goes into affect in July 2001. 

Getting Everyone on the Same Page 

Some medical associations and other critics of the OCR guidance 

strongly oppose requirements that doctors who accept Medicaid funds 

provide and pay for interpreter services for patients with limited English speaking abilities. The high cost of the requirements will place an 

“unreasonable burden” on physician practices, critics say. OCR officials maintain that the guidelines do not represent a new initiative but 

are intended to more fully explain existing policies in place to enforce 

Title VI of the Civil Rights Act of 1964. 

Although some physicians and other organizations may feel the 

OCR guidance is burdensome, there are ways to get everyone on the 

same page. A 1995 study conducted by the New York Task Force on 

Immigrant Health, Access through Medical Interpreter and Language 

Services, found that motivation to develop an interpreter program is 

often shaped by several factors. These include: pressure from physicians; a desire to gain a larger share of the market through increased 

patient volume; the threat of malpractice law suits; a response to the 

influx of refugees and immigrants; and the fact that providing inperson interpreter services is more cost-effective than telephone interpreter services. 

Federal funds are available for States’ expenditures related to the 

provision of oral and written translation administrative activities and 

services provided for the Health Care Financing Administration’s State 

Children’s Health Insurance (SCHIP) and Medicaid programs. 

Some of the most common complaints OCR works to resolve 

include: failing to inform LEP persons of the right to receive free 

interpreter services or requiring them to provide their own interpreter; 

or providing services to LEP persons that are not as effective as those 

provided to persons with proficiency in English. 

In cases where OCR has found health care organizations to provide inadequate access for LEP patients, the agency has required these 

agencies to establish a system for tracking LEP clients and client needs. 

It has also required organizations to publicize the availability of no cost 

programs and services in non-English community media outlets and 

to provide cultural sensitivity training for staff. 

For information on the OCR guidance, go to http://www.hhs.gov/ 

ocr/lep/ or call OCR at (800) 368-1019. To contact the Interpreter 

Services Program at University of Massachusetts Memorial Medical Center, call (508) 856-5793. MMIA can be reached at (617) 636-5479.

Good Communication is Good Medicine 

In a recent study conducted by the Office of Ethics and Health Policy Initiatives at the Albert Einstein 

Healthcare Network in Philadelphia, focus group participants who were limited-English-proficient felt that 

their ability to communicate with providers was restricted. One focus group participant in the 1999 study, 

Approaches to End-of-Life Care in Culturally Diverse Communities, commented, “If you don’t speak English, 

you’re a handicap. You’re going to take a long time to deal with. I’m going to leave you for last, and I’m going 

to help that person who speaks English.” Richard Lerner, MD, a general practitioner at the University of 

Massachusetts Medical Center in Worcester, admits that it does take more time to use an interpreter. “But 

without them, the interaction between provider and patient would be limited,” he said. 

In 1999, the Agency for Healthcare Research and Quality sponsored a workshop on cultural competency in health systems, entitled Providing Care to Diverse Populations: State Strategies for Promoting Cultural 

Competency in Health Systems. Workshop presenters indicated that research and anecdotal evidence suggest 

that the improved communication between doctors and patients leads to greater patient satisfaction. 

Looking for more information on communicating in health care? Check out the third edition of Health 

Communication: Strategies for Health Professionals, by Peter G. Northouse, Ph.D, and Laurel L. Northouse. 

The 1998 book, which provides health care professionals with theory-based strategies they can use to 

improve communication with patients, families, and other health care professionals, includes a chapter on 

intercultural communication.

Office of Minority Health Resource Center 2 U.S. Department of Health and Human Services